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At a recent COVID-19 daily briefing, the Home Secretary, Priti Patel, suggested that the government is reviewing whether it should continue requiring overseas NHS staff to pay the immigration health surcharge. This followed calls from members of parliament to stop doing so and a public petition to the same effect.

The current focus on charges for NHS workers is understandable. Everyone working in health care is under immense pressure responding to COVID-19 and international staff appear to be particularly at risk from the virus. Over half of health care workers who had died of the virus were born outside the UK, up to 22 April 2020.

But the risk of this focus is that we fail to consider the policy as a whole. We need to look at the evidence on the surcharge for all migrants who must pay it – not just those currently in the news.

What is the immigration health surcharge?

The surcharge is a visa fee for access to NHS services for people coming from outside the European Economic Area (EEA) to work, study or join family in the UK for more than 6 months (but not for people applying to stay permanently). Certain groups of people are exempt from the charge, including asylum seekers, victims of trafficking, and diplomats. The government has committed to extending the surcharge to EEA migrants after Brexit.

The surcharge is distinct from the (similarly controversial) upfront charging regime for so-called ‘overseas visitors’ to use most NHS secondary care services – this is applied to people on ‘visitor’ or short-term (6 months or less) visas and undocumented migrants.

In March, the government announced that it will increase the surcharge from the current rate of £400 per year per person to £624 per year per person, from October 2020 (the rate for children, students and those on the youth mobility scheme will be £470). The cost is paid upfront for the whole period a visa covers. So, someone applying for a 5-year Tier 2 visa would pay £3,120 at the proposed new rate, on top of other fees.

Problems with the policy

The coalition government introduced the surcharge in 2015, initially at £200 per year, to ensure ‘those coming to live in the UK make an appropriate financial contribution to the cost of their healthcare.’ Successive governments have used similar reasoning for the surcharge, implying that without it, migrants in the UK do not contribute enough to the NHS.

The NHS is funded primarily through taxation. People living in the UK pay various taxes – this includes those who have migrated here and who pay the surcharge, whether they are working, studying, or caring for their family. Not everyone contributes the same, but ‘access to NHS services is based on clinical need, not an individual’s ability to pay.’ The surcharge effectively makes people pay twice, amounting to a ‘double taxation’ to use the health service.

Despite this, Chancellor of the Exchequer Rishi Sunak announced the latest increase to the surcharge in the March Budget, saying that the current rate ‘doesn’t properly reflect the benefits people receive’. It is unclear how this conclusion has been reached and there is no publicly available analysis supporting the proposed rate of £624. The Department of Health and Social Care confirmed that the original figure announced during the election (£625) came from an unpublished document. Our recently published Health Foundation research shows that migrants use NHS services less frequently than people born in the UK. And existing studies on the fiscal effects of migration find that the overall difference between taxes received because of migration to the UK and the costs of providing services and benefits to migrants is relatively small compared to the size of the economy. In suggesting that migrants do not contribute enough to the care they receive, the political discourse about the surcharge feeds a false narrative that migrants are to blame for pressures on the health service. The evidence tells us they are not.

Migrants are also a vital part of the health and social care workforce. Many of the almost one in four UK hospital workers who were born outside the UK are among those asked to pay the additional charge for access to the very services that they provide. And, with around 100,000 vacancies, the NHS needs to recruit even more staff from abroad. Charging people comparatively high visa fees to come to the UK contradicts policies to support international recruitment into the health service. Nurses might reasonably be put off coming to work in the UK by the prospect of paying nearly 10% of their annual salary on the surcharge (at the current rate). Recognising this, many NHS employers offer to cover the cost for staff they recruit from abroad, either in full or as a loan. In such cases, the NHS ends up paying a charge apparently introduced to help fund it.

Looking at the surcharge in the round

Focusing on why the government is charging people working in the NHS is understandable in the current context. But this is only one aspect of the policy.

Over the years, Labour, coalition and Conservative governments have justified proposals to introduce or increase charges for migrants to use the NHS by saying that it is not an ‘international’ health service. But the NHS is not just ‘powered by love’, it is powered by taxes and its workforce, both of which international migration contributes towards. Any government review should look at the immigration health surcharge policy in its entirety.

Lucinda Allen (@LucindaRAllen) is Policy Officer at the Health Foundation.

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